1Department of Anaesthesiology and Reanimation, Kütahya Gediz State Hospital, Kütahya, Turkey 2Department of Cardiology, Kütahya Gediz State Hospital, Kütahya, Turkey
3Department of Anaesthesiology, Adnan Menderes University Faculty of Medicine, Aydın, Turkey 4Department of Algologie, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
Submitted: 16.03.2018 Accepted after revision: 11.09.2018 Available online date: 25.09.2018 Correspondence: Dr. Ferdi Gülaştı. Kütahya Gediz Devlet Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Kütahya, Turkey. Phone: +90 - 505 - 492 96 50 e-mail: ferdigulasti@gmail.com
© 2021 Turkish Society of Algology
*The current affiliation of the author: Department of Anaesthesiology and Reanimation, Bursa City Hospital, Bursa, Turkey **The current affiliation of the author: Department of Cardiology, Bursa City Hospital, Bursa, Turkey
Özet
Kronik refrakter angina pektoris tedavisine medikal yaklaşım, lazer revaskülarizasyon, transmyokardial lazer revaskülarizasyon, angiogenesis, growth faktör gen terapisi, torakal epidural anestezi ve spinal kord simülatörü kullanılmakla birlikte, unilateral sol stellat ganglion blokajı bir alternatif olarak önerilmektedir. Özellikle yaşam süresi kısa olan hastalarda tercih edilebilecek bir palyatif bir girişim olarak düşünülmelidir. Bizde 66 yaşında erkek hasta son dönem kalp yetersizliği ile takip edilen ve kronik refrakter angina pektorisin tedavisinde unilateral sol stellat ganglion blokajı yapılan olguyu sunduk.
Anahtar sözcükler: Kronik refrakter angina pektoris; son dönem kalp yetmezliği; palyatif tedavi; unilateral sol stellat ganglion blokajı. Summary
In addition to medical approaches, laser revascularization, transmyocardial laser revascularization, angiogenesis, growth fac-tor gene therapy, thoracic epidural anesthesia, and spinal cord simulation are used to treat chronic refracfac-tory angina pecfac-toris. A unilateral left stellate ganglion block is another alternative. It may particularly be considered as a palliative intervention in patients with a short life span. Described here is the case of a 66-year-old male patient for whom a unilateral left stellate gan-glion blockade was used to treat chronic refractory angina pectoris.
Keywords: Chronic refractory angina pectoris; late heart failure; palliative treatment; unilateral left stellate ganglion blockade.
Introduction
In recent years, due to the improvements in the treat-ment of coronary artery disease and other areas of medicine, life expectancy is increasing and the number of patients with cardiac disease is increasing. In addi-tion to medical treatment, unilateral left stellate gangli-on blockade can be used to treat angina-related chest pain. Although the use of chronic refractory angina pectoris is not common in patients with no curative car-diac treatment chances, unilateral left stellate ganglion blockade is an attempt to achieve palliative success. We present a patient with chronic refractory angi-na pectoris who has recently been diagnosed with
heart failure and who underwent unilateral left stel-late ganglion blockade.
Case Report
A 66-year-old male patient admitted to the emer-gency room with chest pain and shortness of breath. The patient has been followed up with coronary artery disease, heart failure, and diabe-tes mellitus type 2 diagnoses, and the diagnosis of ST elevation myocardial infarction (NONSTEMI) was followed up with coronary intensive care unit. 2 coronary artery bypass grafting (CABG) were performed before and subsequently was
percuta-Stellat ganglion blockage in the treatment
of chronic refractory angina pectoris
Kronik refrakter angina pektoris tedavisinde stellat ganglion blokajı
Ferdi GÜLAŞTI,1* Sevil GÜLAŞTI,2** Sinem SARI,3 Osman Nuri AYDIN4
Agri 2021;33(1):46–49 doi: 10.5505/agri.2018.58224
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neous intervention was applied to the circumflex artery (CX), followed by 2 (CX) and percutaneous interventions was applied to the left coronary ar-tery (LMCA). On echocardiography; left ventricular ejection fraction (EF) was assessed as 25%. The lab-oratory values of the patient were pathologically determined as blood glucose 204 mg/dl, troponin 372 and haemoglobin 10.4 gr/dl.
The patient had to go to the hospital in the last year, 11 times with decompensated heart failure and per-sistent angina pectoris. In the recent coronary angi-ography of the patient; LMCA 90%; CX proximal 99%; 99% proximal left anterior descending artery (LAD); 99% in the right coronary artery 99% narrow artery and diffuse atherosclerosis in all coronaries were observed and the patient’s saphenous grafts were found to be occluded (Fig. 1). The patient underwent a LMCA bifurcation and further attempts to be real-ized by cardiology team were considered risky. Med-ical treatment of the patient was as follows; ramipril 2.5 mg, metoprolol 50 mg, spirolactone 25 mg, tica-grelol 90 mg, acetylsalicylic acid 100 mg, furosemide 40 mg, ranolozin 375 mg and trimatezadin 35 mg. The patient was evaluated in cardiology and algol-ogy clinic for pain control upon since reattemptive invasive intervention wasn’t considered by the car-diology-cardiovascular council. Because the patient had terminal period heart failure, stellate ganglion blockade was decided.
The patient was treated with 1 mg intravenous mida-zolam + 50 mcg fentanyl, after 6, vertebra-level scopi coincidence with contrast material, ganglion block-ade with left stellate gangliona 40 mg bupivacain + 8 mg dexamethasone (Fig. 2). The angina complaint of the patient, who had no complication after the pro-cedure, disappeared. The patient died due to decom-pensated heart failure 3 days after the procedure.
Discussion
It is thought that there are special nociceptors in the heart. Heart-related pains are common and mod-erate. In contrast to pain severity, nausea, vomiting due to neuroendocrine stress response, blood pres-sure and heart rate changes can be accompanied by the actual visceral pain as well as the reflected pain spreading to the upper part of the neck, shoulder, chest and abdominal wall can be seen.
Angina pectoris refractory to medical therapy, angi-oplasty and coronary bypass surgery cannot be con-trolled with a combination of, angina due to the fact that coronary insufficiency is a chronic condition that is characterized by the presence of angina.[1]
The patient should be evaluated by the heart team, where the ischemic origin of the angina and the re-vascularization cannot be applied. The majority of patients with ischemic heart disease can be treated with medication and revascularization procedures. While the development of cardiovascular care in-creases the number of patients with end-stage coro-nary artery and refractory anger also increases.How-ever, there is still no standard approach to refractory angina pectoris. In these patients, quality of life has deteriorated due to repetitive and continuous pain, poor general health status, psychological distress
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47 JANUARY 2021
Figure 1. (a, b) LMCA 90_; CX proximal 99_; 99_ stenosis at LAD proximal. (c) 99_ stenosis in right coronary artery. (d) Post LMCA intervention.
(b)
(d) (a)
(c)
Figure 2. Unilateral left stellat ganglion blockage done for chronic refractory angina pectoris.
and limited activity.[2] In order to exclude the
devel-opment of a new disease that can be treated with revascularization, patients are advised to have regu-lar angiography. Our patient was frequently admit-ted to emergency room with recurrent chest pains and had a severe activity limitation.
In addition to medical treatment in patients with chronic refractory angina pectoris, additional treat-ment methods include laser revascularization, trans-myocardial laser revascularization, angiogenesis, growth factor and gene therapy.[3] In addition, the
specialists of algology or anaesthesiology are in-volved in the treatment with thoracic epidural an-aesthesia for palliative purposes, unilateral left stel-late ganglion blockage and spinal cord simulator.[3] It
appears that the unilateral left stellar ganglion block-ade is not a protocol for the use of cardiac patholo-gies. In addition to persistent angina patients with unilateral left stellar ganglion blockade, there are case reports in the literature used in the treatment of long QT syndrome and refractory ventricular tach-ycardia (VT storm).[4,5] One-sided stellat ganglion
blockage can only be done in the form of a block with local anaesthetic agent; local anaesthetic agent +6% phenol mixtures can be done applied. After di-agnostic block, stellar ganglia radiofrequency ther-mo coagulation can also be applied.
Cervicotoraxic (stellate) block is an attempt to di-agnose and treat the symptoms of the head, neck, upper chest and upper extremities of complex re-gional pain syndromes (CRPS), sympathic pain and
symptoms.[6] Although the technique used
wide-ly during stellate ganglionic blockade is anterior paratracheal technique, lateral and posterior ap-proaches are also defined.[6]
SGB can be applied with two finger methods from C6 (Chassignac’s tubercle) and C7 levels.[6] It provides
blockages from all cervical ganglions and upper tho-racic ganglions to T5 ganglions depending on the drug volume. At the end of the operation, pocosis, myositis, enthaltymia, nasal deconjesion and anhro-zia in the neck and Horner’s syndrome occurs at the same side.[6,7] Because it is easier to palpate the SGB,
as it is more distant from the pleura, and because the risk of vertebral artery puncture is lower, it is pre-ferred to do it at C6 level.[6] In this study, we aimed to
investigate the relationship between the severity of
coronary artery disease and the risk of coronary ar-tery disease in patients with coronary arar-tery disease (CAD). In our case, the anterior paratracheal stellate ganglion blockade was performed with two fingers and the complication was not developed.
In a prospective study they performed, Saraste et al., found changes in myocardial perfusion reserve in patients who underwent SCS treatment for refrac-tory angina pectoris.[8] Patients over 80 years of age
who were admitted as contraceptive for SCS treat-ment ,those with ventricular injection fraction <40%, acute coronary syndrome, decompensated heart failure, VF, ventricular tachycardia continuing for 3 months, severe asthma, 2nd and 3rd degree AV block
patients were not included in the study.[9] In addition
to being EF: 25% of our patient, recent heart failure is present, since life expectancy of less than 1 year assessed by the heart team we thought it would not be suitable for SCS treatment. However, because the aneurysm was severe, we thought that thoracic epi-dural anaesthesia or unilateral left stellate ganglion blockade could be applied. We considered that par-tial injection of thoracic epidural anaesthesia should be performed, the epidural catheter should be kept in place, but there is no catheter in the left unilater-al ganglia block, and the number of invasive proce-dures would provide a smaller number of long-term blockages. In our patient, we provided unilateral left stellate ganglion blockade without complications.
Result
Cardiology, anaesthesiology and algology experts should keep in mind that unilateral left stellate gan-glion blockade is a part of palliative care in patients with chronic refractory angina during the last stage of heart failure.
Informed Consent: Written informed consent was ob-tained from the patient for the publication of the case report and the accompanying images.
Conflict-of-interest issues regarding the author-ship or article: None declared.
Peer-rewiew: Externally peer-reviewed.
References
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joint guidelines. Can J Cardiol 2012;28(2 Suppl):S20–41. 2. Brorsson B, Bernstein SJ, Brook RH, Werkö L. Quality of life
of patients with chronic stable angina before and four years after coronary revascularisation compared with a normal population. Heart 2002;87(2):140–5. [CrossRef]
3. Chumburidze VB, Kharchilava NA, Aladashvili AV. The prob-lem of chronic refractory angina pectoris. Georgian Med News 2005;(118):26–8.
4. Rajesh MC, Deepa KV, Ramdas EK. Stellate Ganglion Block as Rescue Therapy in Refractory Ventricular Tachycardia. Anesth Essays Res 2017;11(1):266–7. [CrossRef]
5. Egawa H, Okuda Y, Kitajima T, Minami J. Assessment of QT interval and QT dispersion following stellate ganglion block using computerized measurements. Reg Anesth
Pain Med 2001;26(6):539–44. [CrossRef]
6. Sinem Sarı, Osman Nuri Aydın. Complication belong to Stellate ganglion blockade after cervical trauma. Agri 2014;26(2):97–100. [Article in Turkish] [CrossRef]
7. Cousins MJ, Bridenbaugh PO. Neural Blockade. 3rd ed.
New-York: Lippincott- Raven; 1998. p. 411–47.
8. Schlack W, Schäfer S, Thämer V. Left stellate ganglion block impairs left ventricular function. Anesth Analg 1994;79(6):1082–8. [CrossRef]
9. Saraste A, Ukkonen H, Varis A, Vasankari T, Tunturi S, Taittonen M, et al. Effect of spinal cord stimulation on myocardial perfusion reserve in patients with refrac-tory angina pectoris. Eur Heart J Cardiovasc Imaging 2015;16(4):449–55. [CrossRef]
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